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Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Answer: In the patient that you describe: suspected cardiogenic shock with hypotension and crackles; yes you are correct that they cannot receive a bolus or CPAP per the Medical Directives. The concern being that if they already have fluid overload (crackles) that a bolus could worsen their respiratory status. Similarly, CPAP can worsen their hypotension via decreased venous return due to an increase in intra-thoracic pressure. Once you bring them to hospital, both interventions may immediately be performed. But, this is because the consequences of these actions (respiratory failure and hypotension) are much more easily managed with the personnel, equipment and drugs that are just not available pre-hospital. That being said, the one thing that you could do for this patient with suspected cardiac ischemia, that has not yet been mentioned, with proven mortality benefit is give ASA.